Design and construction professionals
Professional insurance portfolio proposal form
The Hiscox Professional Insurance Portfolio is designed to meet all the insurance needs
of a professional business.
Which sections
should you
complete?
This proposal form
Section
Title
Should you complete it?
1.
Your business
All businesses must complete this section
2.
Subsidiary and associated Please complete this section if you require cover under
companies
any section of cover for subsidiary or associated
companies
3.
Professional indemnity
All business must complete this section
4.
Management liability
Please complete this section if you require this cover
5.
Cyber and data
Please complete this section if you require this cover
6.
Claims
All businesses must complete this section
7.
Declaration
All businesses must complete this section
The purpose of this proposal form is for us to find out who you are and what you do with a view
to making a proposal for one or more products from the Hiscox Professional Insurance Portfolio.
It does not oblige either party to enter into a contract of insurance.
Insurance is a contract of utmost good faith. This means that the information you provide in this
proposal form must be complete, accurate and not misleading. It also means that you must tell
us about all facts and matters which may be relevant to our consideration of your proposal for
insurance. Any failure by you in this regard may entitle us to treat this insurance as if it never
existed.
If a contract of insurance is agreed between us this proposal form, and all other information
given to us by you or anyone on your behalf, whether it is written, verbal or otherwise, will form
the basis of the contract.
Whoever signs this form must be a director, officer, board member or senior manager of the
proposer and must make all the necessary enquiries of their fellow directors, officers, board
members, senior managers and employees to enable all the questions to be answered
completely, accurately and clearly.
PF-PIP-IRE-D&C(2)
10889 08/14
Design and construction professionals
Professional insurance portfolio proposal form
Section 1 - Your
business
You must complete this section.
1.1 Your business
Business name
Main address
Post code
Year business established
1.2 Your employees
Your total number of employees (including subsidiaries)
1.3 Subsidiary or associated
companies
Do you require cover (under any section to be insured) for any subsidiary or
associated companies?
Yes
No
If Yes, you must ensure that all other information you give in this proposal form incorporates
that for the subsidiary or associated companies, including income and claims information.
You must also complete section 2 – Subsidiary and associated companies.
1.4 Additional liabilities
Is cover required for anything other than work undertaken by the firm(s)
identified on this proposal form? This may include a predecessor in business
or liability of one of your partners or principals relating to work undertaken
elsewhere.
Yes
No
If Yes, please provide details:
1.5 Your total income
Total income
1.6 Work outside Ireland
Last completed financial year
Year ending:
/
/
Current year
Year ending:
/
/
€
€
Do you undertake any activities outside Ireland or for clients based outside
the Ireland?
Yes
No
If Yes, please provide details:
1.6 Your experience
Please confirm that one or more of the principals has at least three years’
experience in the relevant industry:
Yes
No
If No, please provide CVs for all principals.
1.7 Membership of
professional organisations
Is your business a member of any professional organisations or trade
associations?
If Yes, please provide details:
PF-PIP-IRE-D&C(2)
10889 08/14
Yes
No
Design and construction professionals
Professional insurance portfolio proposal form
Section 2 Subsidiary or
associated
companies
2.1 Subsidiary companies
Please complete this section if you require cover under any section of cover for
subsidiary or associated companies.
We can extend this insurance to include subsidiary or associated companies for which you
require cover provided that:
a.
a complete list of the companies is given below (or on a separate sheet if necessary); and
b.
the turnover and claims information declared on this proposal form incorporates that for
the subsidiary or associated companies; and
c.
all other information you give in this proposal form incorporates that for the subsidiary or
associated companies.
Subsidiary company means any company in which the company named in section 1, directly or
indirectly, owns more than 50% of the book value of the assets or outstanding voting rights.
Please provide the following details for all subsidiary companies to be insured.
Name
2.2 Associated companies
Country
Please provide the following details for any associated companies to be insured below:
Name
PF-PIP-IRE-D&C(2)
10889 08/14
Main/registered address including
postcode
Main/registered address including
postcode
Country
Design and construction professionals
Professional insurance portfolio proposal form
Section 3 Professional
indemnity
You must complete this section.
3.1 Business activities - your
description
Please provide a description of your business activities in your own words including any
specialisations:
3.2 Past business activities
Have your business activities varied significantly from those described in
section 3.1 in the last five years?
If Yes, please provide details:
Yes
No
Do you expect any significant changes to the activities described in section
3.1 in the next 12 months?
If Yes, please provide details:
Yes
No
Yes
No
3.3 Future business activities
3.4 Techniques and practices Do all your contracts involve well-established techniques and practices?
If No, please provide details:
3.5 Specific activities
Have you undertaken contracts involving any of the following in the last five years?
a.
Manufacturing plant?
Yes
No
b.
Power plant?
Yes
No
c.
Sewerage and water systems*?
Yes
No
d.
Petrochemicals and refineries?
Yes
No
e.
Roads*, bridges, tunnels and dams?
Yes
No
f.
Harbours and jetties?
Yes
No
g.
Mines and associated works?
Yes
No
h.
The installation of symphonic drainage systems?
Yes
No
*other than as part of the infrastructure for a development where you are also constructing the buildings.
If Yes to any of a. to h. above, please give full details on a separate sheet.
3.6 Consortiums, joint
ventures and PPP
a.
Have you ever undertaken a contract as a member of a consortium or
joint venture?
Yes
No
b.
Have you ever undertaken a contract which forms part of a Public Private
Partnership (PPP) project?
Yes
No
If Yes to any of a. or b. above, please give full details on a separate sheet.
PF-PIP-IRE-D&C(2)
10889 08/14
Design and construction professionals
Professional insurance portfolio proposal form
3.7 Design and construction
income breakdown
Please provide a breakdown of your total income stated above according to the following
categories:
Last completed
financial year
Year ending:
/
/
Current year
Year ending:
/
/
1. You undertake the construction/installation
and:
a. you are responsible for the design^ and
the design^ is undertaken by your own
partners, directors or employees
%
%
b. you are responsible for the design^ and
the design is undertaken by third parties
appointed by you, on your behalf or
whose appointment is novated by you
%
%
c. you have no responsibility for any aspect
of the design^ (i.e. you work to designs
provided to you by your client or main
contractor with no input from you
%
%
%
%
2. All other turnover - please provide details
below
^Design means any design or specification, feasibility study, technical information, calculation or survey
carried out in relation to a contract.
3.8 Contracts
a.
Please give details of the five largest contracts (in terms of total contract/project value) you
have undertaken in the past five years where you have had responsibility for design or
other professional services:
Year
Name of client
and nature of their
business
Activities
undertaken by
you
Total
contract
value
Your
contract
value*
Your fees
from
contract
*Your contract value: please give the total value of the part of the part of the contract you are directly
involved in, including raw materials etc.
PF-PIP-IRE-D&C(2)
10889 08/14
Design and construction professionals
Professional insurance portfolio proposal form
b.
Please give details of the two largest contracts you expect to commence in the forthcoming
year where you have responsibility for design or other professional services:
Name of client
and nature of their
business
3.9 Sub-contractors
a.
Activities to be
undertaken by you
Total contract
value
Your fees from
contract
Do you use independent sub-contractors?
Yes
If Yes, what were the total fees paid to them in the last financial year?
No
€
i.
Architectural
%
ii.
Structural engineering
%
iii.
Mechanical engineering
%
iv.
Civil engineering
%
v.
Soil engineering
%
vi.
Electrical engineering
%
vii. Heating and ventilation engineering
.
ix. Other – please give full details:
%
%
b.
Do you ever accept liability for professionals appointed by others by way
of novation or other legal agreement?
c.
Do you now, and have you in the past, always ensured that you maintain
full rights of recourse against any third parties appointed by you, on your
behalf, or whose appointment is novated to you, and that these third
parties hold and maintain professional indemnity insurance with a limit of
indemnity at least equal to that held by you?
Yes
No
Yes
No
Yes
No
If No, please provide full details on a separate sheet.
3.10 Previous insurance
Have you ever bought professional indemnity insurance in the past?
If Yes, please provide details of your most recent policy:
Name of
insurer
3.11 Cover required
Excess
€
€
Premium
Renewal
date
No. of years
continuously
held
Please tick the limit of indemnity required:
€1,300,000
PF-PIP-IRE-D&C(2)
10889 08/14
Limit of
indemnity
€2,600,000
€6,500,000
Other:
€
Design and construction professionals
Professional insurance portfolio proposal form
Section 4 Management liability
Optional – only complete this section if cover for directors and officers’ liability,
corporate legal liability and employment practices liability is required.
4.1 Directors and officers’ and Please provide confirmation that you and all of your subsidiaries:
corporate legal liability
a. are an Irish registered limited company;
Yes
No
Yes
No
iii. a recruitment consultant or staffing agency.
Yes
No
d.
have been trading for at least two years;
Yes
No
e.
have not made a loss in the last 12 months or do not expect to make a
loss in the next 12 months;
Yes
No
f.
Have declared a positive net worth in your latest annual accounts;
Yes
No
g.
have not had your accountants qualify their opinion in your latest annual
accounts;
Yes
No
h.
have no assets in or turnover from the USA?
Yes
No
i.
have reviewed your health and safety policies and procedures in the last
12 months;
Yes
No
Yes
No
b.
are not listed on any stock exchange;
c.
are not:
j.
4.2 Employment practices
liability
i.
a firm offering professional legal advice; or
ii.
a firm directly regulated by the Central Bank of Ireland; or
segregate duties so that at least dual control exists on signing cheques,
issuing instructions for disbursement of assets or funds, fund transfer
procedures or investments for amounts in excess of €3,250.
Employment practices liability can only be taken with directors and officers’ liability and
corporate legal liability, it cannot be taken standalone.
Please confirm that you and all of your subsidiaries:
a.
have not made any redundancies in the last 12 months;
Yes
No
b.
do not anticipate any redundancies in the next 12 months;
Yes
No
c.
have written employment and grievance policies which are communicated
to all new and existing employees;
Yes
No
review and gain approval from external legal or human resources advisers
prior to any disciplinary action or employee contract terminations?
Yes
No
d.
If you have answered No to any of the above, please provide full details below (please attach
additional sheet if necessary):
PF-PIP-IRE-D&C(2)
10889 08/14
Design and construction professionals
Professional insurance portfolio proposal form
Section 5 - Cyber
and data
Please provide details of personal information (in both electronic and non-electronic form) you
process or store using the following table. N.B. this should include information relating to
employees (past, present and prospective), as well as third-parties.
Type of sensitive information transmitted, processed or stored:
Names,
addresses
and email
addresses
Individual
taxpayer
ID/NI
numbers
Driver’s
license,
passport
or other ID
numbers
Financial
account
records
Payment
card data
Other:
Please
specify
Number of
records
transmitted
or
processed
per year
Maximum
number
of records
stored
on your
network at
any one
time
Always
encrypted
while atrest on the
network?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Always
encrypted
while intransit
within and
out of the
network?*
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Always
encrypted
on mobile
computing
devices?**
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Always
encrypted
on portable
data
storage
media?***
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
*including on wireless networks, in file transfers and in email.
**including laptops, tablets, mobile telephones, PDAs.
*** including USB sticks, flash drives, magnetic tapes.
1.
Do you have a defined process implemented to regularly patch your
systems and applications?
Yes
No
2.
Do you use anti-virus software and regularly apply updates/patches?
Yes
No
3.
Have you installed and do you maintain a firewall configuration to
protect your system?
Yes
No
Do you back up files on your system (including your website) at least
weekly and store off site?
Yes
No
5.
Are all passwords changed at least every 60 days?
Yes
No
6.
Do you have written clearance procedures in place regarding use,
licensing and consent for third-party content used by you on your
website or in promotional materials?
Yes
No
4.
PF-PIP-IRE-D&C(2)
10889 08/14
Design and construction professionals
Professional insurance portfolio proposal form
7.
Are you compliant with the most recent applicable Payment Card
Industry Data Security Standards (PCI DSS)? If Yes:
to what certification level?
Level 1
Level 2
Yes
Level 3
No
Level 4
when was your last assessment?
8.
PF-PIP-IRE-D&C(2)
10889 08/14
Please give details of any IT security incidents, privacy breaches or other circumstances
you have suffered:
Design and construction professionals
Professional insurance portfolio proposal form
Section 6 - Claims
You must complete this section. Please complete the claims questions for any risk now
to be insured.
6.1 General
In relation to your professional business activities, are you after reasonable enquiry aware of:
a.
any matter which may lead to a claim against you.
This includes:
i.
a shortcoming or problem in your work known to you which you
cannot reasonably put right;
Yes
No
a complaint about your work or anything you have supplied which
cannot be immediately resolved;
Yes
No
iii.
an escalating level of complaint on a particular project;
Yes
No
iv.
a client withholding payment due to you after any complaint.
Yes
No
any loss from the dishonesty or malice of any employee or selfemployed freelancer.
Yes
No
any loss from the suspected dishonesty or malice of any employee or
self-employed freelancer.
Yes
No
any matter which may give rise to a claim against your predecessors in
business or any past director, officer, board member, senior manager or
employee.
Yes
No
ii.
b.
c.
d.
If you answered Yes to any of the above, please provide full details:
6.2 Your directors
Have you or any of your directors at any time either personally or in any business capacity:
a.
been declared bankrupt or become insolvent or made any voluntary
arrangement with creditors or been subject to enforcement of a
judgment debt?
Yes
No
b.
been a director or had a controlling interest in any company, firm or
business entity which has entered into a voluntary arrangement with
creditors or been subject to any application for liquidation,
administration, receivership or to enforcement of a judgment debt?
Yes
No
If the answer to a. and/or b. above is Yes, please give full details on a separate sheet.
6.3 Professional indemnity
6.4 All others covers
Has any claim, whether successful or not been made against you or your
predecessors in business or any past or present director, officer, board
member, senior manager or employee (whether previously insured or not)?
No
In respect of the following insurance covers - management liability and internet and email:
Has any claim or loss, whether successful or not, ever occurred or been
made against you or your predecessors in business or any past or present
director, officer, board member, senior manager or employee in respect of
any risk now to be insured under the insurance covers listed above (whether
previously insured or not)?
PF-PIP-IRE-D&C(2)
10889 08/14
Yes
Yes
No
Design and construction professionals
Professional insurance portfolio proposal form
If the answer to 6.3. and/or 6.4. is Yes, please give full details below:
Date
Details
Amount
Remedial action
Please continue on a separate sheet if necessary.
6.5 Management liability
a.
b.
c.
d.
In the last five years, have the company or any insured person been the
subject of an investigation by any official body or institution?
Yes
No
In the last five years, have there been any claims and or investigations
made against the company, its directors, officers or employees which
may have been covered by this policy had it been in force?
Yes
No
After enquiry, are the company or its directors,officers or employees
aware of any fact, circumstance, allegation or incident which may give
rise to a claim under the proposed policy?
Yes
No
In the last five years you have not been the subject of any employment
claim or investigation?
Yes
No
Yes
No
If Yes, please provide full details:
6.6 Previous insurance
Have you ever had any insurance or proposal cancelled, withdrawn, declined
or made subject to special terms?
If Yes, please provide details:
Date
PF-PIP-IRE-D&C(2)
10889 08/14
Details
Design and construction professionals
Professional insurance portfolio proposal form
Section 7 Declaration
You must complete this section.
7.1 Material information
Please provide us with details of any information which may be relevant to our consideration of
your proposal for insurance. If you have any doubt over whether something is relevant, please
let us have details.
7.2 Your information
By signing this proposal form, you consent to the Hiscox group of companies (collectively
referred to as Hiscox) using the information we may hold about you or others related to your
policy for the purposes of providing insurance and handling claims, if any, and to process
sensitive personal information about you or others related to your policy where this is necessary
(for example health information or criminal convictions). This may mean Hiscox has to give
some details to third parties involved in providing insurance cover. These may include insurance
carriers, third-party claims adjusters, fraud detection and prevention services, third party service
providers, reinsurance companies, insurer tracing offices and insurance regulatory authorities.
Where such sensitive personal information relates to anyone other than you, you must obtain
the explicit consent of the person to whom the information relates both to the disclosure of such
information to us and its use by Hiscox as set out above. The information provided will be
treated in confidence and in compliance with all relevant regulation and legislation. You or
others related to your policy may have the right to apply for a copy of this information (for
which Hiscox may charge a small fee) and to have any inaccuracies corrected. For training and
quality control purposes, telephone calls may be monitored or recorded.
7.3 Declaration
I/We declare that (a) this proposal form has been completed after proper enquiry; (b) its
contents are true and accurate and (c) all facts and matters which may be relevant to the
consideration of our proposal for insurance have been disclosed.
Please read the declaration carefully and sign at the bottom.
I/We undertake to inform you before any contract of insurance is concluded, if there is any
material change to the information already provided or any new fact or matter arises which may
be relevant to the consideration of our proposal for insurance.
I/We understand that non-disclosure or misrepresentation of a material fact or matter will entitle
Hiscox Underwriting Ltd to avoid this insurance.
I/We agree that this proposal form and all other information which is provided are incorporated
into and form the basis of any contract of insurance.
Name of director/officer/board member/senior manager
/
Signature of director/officer/board member/senior manager
/
Date
A copy of this proposal should be retained for your records.
7.4 Complaints
Hiscox aims to ensure that all aspects of your insurance are dealt with promptly, efficiently and
fairly. At all times Hiscox are committed to providing you with the highest standard of service. If
you have any concerns about your policy or you are dissatisfied about the handling of a claim
and wish to complain you should, in the first instance, contact Hiscox Customer Relations in
writing at:
Hiscox Customer Relations
Hiscox House
Sheepen Place
Colchester CO3 3XL
United Kingdom
or by telephone on +44(0) 1206 773705
or by email at customer.relations@hiscox.com.
Where you are not satisfied with the final response from Hiscox, you also have the right to refer
your complaint to the Financial Services Ombudsman. For more information regarding the
scope of the Financial Services Ombudsman, please refer to www.financialombudsman.ie.
PF-PIP-IRE-D&C(2)
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Hiscox Underwriting Ltd is authorised by the Financial Conduct Authority in the UK and is
regulated by the Central Bank of Ireland for conduct of business rules.